Jonathan Kay: A Canadian perspective on America’s ideological civil war over health care

To Canadian eyes, America’s ideological war over health policy — which came to a climax in today’s 5-4 U.S. Supreme Court victory for Obamacare — can appear bizarre. Aside from the United States, every OECD country on earth already has a universal health care system. Why do Americans have to be dragged kicking and screaming into a policy choice that the rest of the civilized world decided long ago was a cornerstone of a humane society?

For me, a clue came earlier this year, when I was in New Hampshire covering the campaign for the Republican presidential nomination.

The most interesting part of that campaign was the town halls, in which candidates were forced to depart from their prepared scripts, and answer questions from ordinary citizens. Many of the questions were about medical issues — and often they were very specific. I remember one Ron Paul event at which a woman detailed the challenges she was facing with her Alzheimer’s-afflicted parent. Another attendee spoke about his kidney problems. They wanted to know what Mr. Paul, the most libertarian candidate, would do to help them with their problems.

Americans think a lot about health care — far more than we Canadians do. Even Americans with insurance often face bewildering paperwork in regard to hospital stays, deductibles, and top-ups from public programs such as Medicare, not to mention the elaborate enlistment process — in which a single false answer sometimes can get you disqualified for coverage after the fact. The complexity of all this can be beyond the comprehension of most Canadians: One (insured) American friend of mine, for instance, had a laundry basket full of financial documents to go through after his child was born with complications. In many cases, the difference between bankruptcy and solvency is the technical difference between one medical condition and another.

But in New Hampshire, Ron Paul didn’t dwell much on these technical differences — even though he is a medical doctor who has delivered thousands of babies in his career. His answer to such questions typically was a variation on a single theme: that the health needs of needy Americans can be met at the local level — through charity hospitals, voluntary collectives, and religious organizations — once the federal government and Obamacare are pushed out of the way. He spoke warmly about his experience with these sort of local arrangements by hearkening back to his days as an obstetrics and gynecology specialist in Texas in the 1960s. Dr. Paul, as he then was known, gave discounts to poor patients. On principle, he refused to take money from Medicaid or Medicare.

Opponents of Obamacare often are depicted as cranky conservatives who simply hate big government. Some are like that. But many aren’t: Like Ron Paul, they are prototypical “can do” American optimists, who believe that no problem is too great or too complex that it cannot be solved at the grass-roots level by independent-minded citizens.

The problem is that, when it comes to health care, they’re wrong. In the early 1960s, when Ron Paul started his medical career, U.S. health care spending as a percentage of GDP was about 5%. Now, it is about 17%. Much of that spending goes toward teams of specialists and capital-intensive high-tech diagnostic equipment that are far beyond the means of the sort of neighborhood health clinics and charities that Ron Paul sentimentalizes. That’s why every Western nation on earth, whatever the specifics of their system, runs health care as a large-scale bureaucracy operated by medical technocrats, with substantial public funding and oversight. (This includes the United States, which, even decades before Obamacare, has run overlapping state and federal programs such as Medicare, Medicaid and CHIP, which effectively have pushed the country toward universal health care — albeit in a clumsy, wasteful and fragmented manner.) The massive ideological war over health care in America is essentially a struggle between those who accept the inevitability of this migration toward big-government health care, and those who don’t.

Here in Canada, even conservatives gave up the Ron Paul position decades ago. Yes, we want more private options, and an end to the North Korean-style public monopoly mentality. But not a single mainstream politician in this country demands an end to universal health care. Even back in the day of Tommy Douglas, Canada never had the sort of culture war over universal health care that the United States is now witnessing. The decision to provide care to all citizens was then seen as a policy issue; it did not represent an existential national-identity trauma, as Obamacare has become south of the border.

Canadians lament that they have few national myths. But as the health-care debate shows, an absence of myths makes policy-making easier. In the United States, where the Founding Fathers are treated as secular saints, where many “originalist” judges are trapped in a 1789-era reading of the Constitution, and where conservatives such as Ron Paul still imagine a country of frontier yeomen who can get their health care from neighbours and local well-wishers, Obamacare became a proxy for a larger and more vexing question: Can Americans still afford to entertain 18th-century political reveries when 50-million of their countrymen lack health insurance in the world of 2012?